METHOD OF OPTIMIZING HEALTHCARE SERVICES CONSUMPTION
First Claim
1. A method of optimizing healthcare services consumption, including the steps of:
- assessing a healthcare situation of an employer who provides healthcare benefits to a population that resides and consumes healthcare services in a health economic zone;
identifying a first group of patients from the population likely to generate expensive healthcare claims relative to other patients in the population based on data representing past healthcare claims generated by the population;
periodically determining whether patients in the first group have obtained healthcare services that satisfy predetermined requirements;
identifying a first group of providers in the health economic zone who provide high quality, cost efficient healthcare services relative to other providers in the health economic zone based on data representing past practice patterns of the first group of providers and the other providers;
prompting patients who have not obtained healthcare services that satisfy the predetermined requirements to obtain additional healthcare services to satisfy the predetermined requirements from providers in the first group of providers; and
responding to healthcare requests from the population by determining whether a-patients submitting requests are seeking to obtain healthcare services from providers in the first group of providers, and for a patient requesting services from one of the other providers, taking an action through human intervention to urge the submitting patient to obtain the requested healthcare services from a provider in the first group of providers.
1 Assignment
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Accused Products
Abstract
A method of optimizing healthcare services consumption according to the invention includes the steps of assessing the healthcare situation of an employer providing healthcare benefits to a population, identifying a first group of patients from the population likely to generate expensive healthcare claims based on data representing past claims, periodically determining whether patients in the first group have satisfied certain predetermined healthcare requirements, identifying a first group of providers who provide high quality, cost efficient healthcare services based on the practice patterns of the providers, prompting patients who have not satisfied the predetermined healthcare requirements to obtain services from providers in the first group, and responding to healthcare requests from patients by determining whether the requesting patient is seeking services from a provider in the first group, and, if not, urging the patient to obtain such services from a provider in the first group.
53 Citations
40 Claims
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1. A method of optimizing healthcare services consumption, including the steps of:
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assessing a healthcare situation of an employer who provides healthcare benefits to a population that resides and consumes healthcare services in a health economic zone; identifying a first group of patients from the population likely to generate expensive healthcare claims relative to other patients in the population based on data representing past healthcare claims generated by the population; periodically determining whether patients in the first group have obtained healthcare services that satisfy predetermined requirements; identifying a first group of providers in the health economic zone who provide high quality, cost efficient healthcare services relative to other providers in the health economic zone based on data representing past practice patterns of the first group of providers and the other providers; prompting patients who have not obtained healthcare services that satisfy the predetermined requirements to obtain additional healthcare services to satisfy the predetermined requirements from providers in the first group of providers; and responding to healthcare requests from the population by determining whether a-patients submitting requests are seeking to obtain healthcare services from providers in the first group of providers, and for a patient requesting services from one of the other providers, taking an action through human intervention to urge the submitting patient to obtain the requested healthcare services from a provider in the first group of providers. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19)
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20. A method of optimizing healthcare services consumption of patients in a healthcare plan provided by an employer and administered by a healthcare quality management firm in a health economic zone that corresponds to the residences of the patients and the locations of providers used by the patients, the method including the steps of:
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ranking providers in the health economic zone based on an analysis of the quality and cost efficiency of practice patterns associated with the providers; dividing the ranking of providers into a first plurality of providers, a second plurality of providers, and a third plurality of providers; responding to a healthcare requests from patients by determining the plurality of providers into which the provider associated with the request falls; urging patients requesting to use a provider in the second plurality of providers to use a provider in the first plurality of providers; urging patients requesting to use a provider in the third plurality of providers to use a provider in the second plurality of providers; conducting a first set of intervention actions corresponding to a first degree of involvement of the healthcare quality management firm in the provision of services by the provider used by the patient if the used provider is in the second plurality of providers; and conducting a second set of intervention actions corresponding to a second degree of involvement of the healthcare quality management firm in the provision of services by the used provider if the used provider is in the third plurality of providers, the second degree of involvement being greater than the first degree of involvement. - View Dependent Claims (21, 22, 23)
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24. A method of optimizing healthcare services consumption by patients of a population in a healthcare plan provided by an employer, the method including the steps of:
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for each healthcare provider in a health economic zone, performing an individual calculation based upon past claims information to determine a cost efficiency index; assigning a non-certified designation to each provider having cost efficiency index that fails to satisfy a first predetermined condition; for each provider, performing an individual analysis based upon the past claims information to determine a service rate; assigning a non-certified designation to each provider having a service rate that fails to satisfy a second predetermined condition; evaluating practice patterns of each provider based upon the past claims information; assigning a non-certified designation to each provider having practice patterns that fail to satisfy a third predetermined condition; assigning a qualified designation to each provider having a cost efficiency index, a service rate, and practice patterns that satisfy the first, second, and third predetermined conditions, respectively; and responding to a request from a patient for healthcare services by urging the patient to obtain the services from a provider having a qualified designation. - View Dependent Claims (25, 26, 27, 28, 29, 30, 31, 32)
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33. A method of optimizing health services consumption of patients in a healthcare plan administered within a geographic area, the method including the steps of:
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ranking providers located in the geographic area based on an analysis of the quality and cost efficiency of practice patterns associated with the providers; dividing the ranking of providers into a first level of providers and a second level of providers; and responding to a healthcare request from a patient requesting services from a second level provider by accessing the ranking of providers to identify providers having a first level ranking located within a selectable distance from the patient, and contacting the requesting patient to urge the requesting patient to use one of the identified first level providers. - View Dependent Claims (34)
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35. A method of optimizing healthcare services consumption, including the steps of:
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assessing a healthcare situation of an employer who provides healthcare benefits to a population that resides and consumes healthcare services in a health economic zone; identifying a first group of patients from the population likely to generate expensive healthcare claims relative to other patients in the population based on data representing past healthcare claims generated by the population; periodically determining whether patients in the first group have obtained healthcare services that satisfy predetermined requirements; identifying a first group of providers in the health economic zone who provide high quality, cost efficient healthcare services relative to other providers in the health economic zone based on data representing past practice patterns of the first group of providers and the other providers; prompting patients who have not obtained healthcare services that satisfy the predetermined requirements to obtain additional healthcare services to satisfy the predetermined requirements from providers in the first group of providers; and responding to healthcare requests from the population by determining whether a patient submitting a request is seeking to obtain healthcare services from a provider in the first group of providers, and, if not, contacting the submitting patient to urge the submitting patient to obtain healthcare services for the request from a provider in the first group of providers.
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36. A method of optimizing healthcare services consumption by patients in a population, including the steps of:
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identifying, based on historical claims data, a first group of providers available to provide high quality, cost efficient healthcare services relative to other providers; and responding to healthcare requests from the population by contacting patients seeking to obtain healthcare services from one of the other providers to urge the patient to obtain healthcare services from a provider in the first group of providers.
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37. A method of optimizing healthcare services consumption of patients in a healthcare plan, the method including the steps of:
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ranking individual providers based on historical claims data; based on the individual rankings, identifying a first group of providers, a second group of providers, and a third group of providers; participating in the provision of healthcare services at a first level for patients choosing to obtain services from a provider in the second group; and participating in the provision of healthcare services at a second level for patients choosing to obtain services from a provider in the third group, the second level corresponding to a greater degree of participation than the first level.
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38. A method of optimizing healthcare services consumption by patients of a population in a healthcare plan provided by an employer, the method including the steps of:
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for each provider servicing the population, performing an individual assessment of past claims information to determine a cost efficiency index, a service rate, and a practice patterns challenge rate assigning a qualified designation to each provider having an acceptable cost efficiency index, service rate, and practice patterns challenge rate; and performing an action after a request for healthcare services by a patient, the action being directed specifically to the requesting patient in an attempt to persuade the requesting patient to obtain the services from a provider having a qualified designation.
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39. A method of optimizing healthcare services consumption of patients in a healthcare plan provided by an employer and a healthcare quality management firm in a health economic zone that corresponds to the residences of the patients and the locations of providers used by the patients, the method including the steps of:
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(A) executing software to access data representing past practice patterns of the providers; (B) ranking each provider based on quality and cost efficiency characteristics of the past practice patterns associated with the provider; (C) dividing the ranking of providers into a first plurality of providers, a second plurality of providers, and a third plurality of providers; (D) responding to requests for healthcare services from patients by determining the plurality of providers into which the provider associated with the request falls; (E) when a patient requests to use a provider in the second plurality of providers, using an electronic communication device to contact the patient before the patient consumes the requested services to urge the patient to use a provider in the first group of providers; (F) when a patient requests to use a provider in the third plurality of providers, using an electronic communication device to contact the patient before the patient consumes the requested services to urge the patient to use a provider in one of the first plurality of providers and the second plurality of providers; (G) when a patient uses a provider in the second plurality of providers, conducting a first set of intervention actions corresponding to a first degree of involvement of the healthcare quality management firm in the provision of services by the provider in the second plurality of providers; and (H) when a patient uses a provider in the third plurality of providers, conducting a second set of intervention actions corresponding to a second degree of involvement of the healthcare quality management firm in the provision of services by the provider in the third plurality of providers, the second degree of involvement being greater than the first degree of involvement.
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40. A method of optimizing healthcare services consumption of patients in a healthcare plan provided by an employer, including the steps of:
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(A) transforming using a computing device past healthcare claims data generated by the patients into data representing a first group of patients likely to generate expensive healthcare claims relative to other patients in the healthcare plan; (B) transforming using a computing device past practice patterns data of providers who provide services to the patients into data representing a first group of providers who provide high quality, cost efficient healthcare services relative to other providers of the patients; (C) periodically determining whether patients in the first group suffer from one or more chronic conditions; (D) determining whether the patients suffering from one or more chronic conditions have obtained healthcare services that satisfy a predetermined set of minimum annual care requirements (MACR) associated with the one or more chronic conditions; and (E) using an electronic communication device to instruct the patients who have not obtained healthcare services that satisfy the predetermined set of MACR to obtain additional healthcare services to satisfy the predetermined set of MACR from a provider in the first group of providers.
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Specification